我国三级公立医院绩效考核指标体系解读与评析

2019年5月国家三级公立医院绩效考核工作全面启动,引起公立医院高度关注。本文首先对我国新医改以来公立医院绩效考核政策和相关工作进行了梳理;其次对国家三级公立医院绩效考核工作主要特点、《国家三级公立医院绩效考核操作手册(2019版)》主要内容、几项特殊指标进行了解读;最后对绩效考核指标体系进行了系统评价,包括指标体系逻辑性、指标权重确定、指标数据质量、指标数值导向性、考核结果可比性、指标体系信效度和可操作性等方面,并提出了相应政策建议。     

三级公立医院绩效考核中人才培养考核指标的思考

人才培养是我国医疗卫生事业和医疗卫生机构健康可持续发展的重要保障,将人才培养情况纳入绩效考核具有十分重要的意义。作者分析国家三级公立医院绩效考核中人才培养指标的内涵及导向,梳理其中需要优化的考核细则,提出医学人才培养考核指标逐步提高与区间范围考核相结合的考核方法建议,为进一步完善人才培养考核的科学性、规范性、同质性、纵向与横向可比性、可操作性提供借鉴。     

基于德尔菲法的医疗联合体综合绩效考核实证研究

目的:基于德尔菲法,探索建立医联体综合绩效考核自评体系。方法:对20位专家进行两轮德尔菲专家咨询,建立医联体综合绩效考核自我评价体系,并对医联体运行绩效进行自我评价。结果:两轮问卷有效回收率分别为100%和90%,最终构建的医疗联合体综合绩效考核自我评价体系包含1级指标5个,2级指标14个,3级指标25个。结论:本研究制订的考核指标具有较高的可靠性和可行性,评价结果能够客观反映医联体运行绩效,为医联体建设自我评价提供借鉴。     

以国家公立医院绩效考核为抓手推进医联体建设

目的通过分析国家公立医院绩效考核结果,探索精准推进医联体建设的方向。 方法以上海市某医联体内部A、B、C 三家医院为例,分析国家三级公立医院绩效考核反馈的2018年相关数据。结果A医院需关注与单病种相关的费用及病死率,提高门诊患者满意度和医务人员满意度;B医院需进一步加强胸痛中心和卒中中心相关疾病的单病种管理,提高住院医师首次参加医师资格考试通过率,医疗信息化建设水平,以及门诊患者满意度;C医院需进一步提升开展疑难手术的能力和医务人员科研能力。结论通过建立医联体医院信息互联互通,以国家公立医院绩效考核为抓手,可以精准推进医联体建设。     

共生理论视角下深圳市妇幼保健机构参与医联体建设实践研究

目的:根据深圳市妇幼保健机构参与医疗联合体(以下简称医联体)的建设情况,为医联体建设背景下妇幼保健机构的发展提出建议。方法:基于实地调研,运用共生理论分析深圳市妇幼保健机构参与医联体建设的共生关系和实践情况。结果:由于存在分工协作机制不合理、配套政策不完善和资源流动不通畅等问题,导致医联体内部联合不紧密,未形成互惠共生关系。结论:建议组建妇幼健康联合体,通过优化分工协作机制、完善相关配套政策和加强卫生信息平台建设来推进现有医联体向互惠共生模式转变。     

考核机制应瞄准功能定位

正分级诊疗是实现健康中国顶层设计的制度安排,而医疗联合体改革则是实现分级诊疗、推进各层级分工协作、优化医疗资源配置的路径之一。目前,关于医联体运行效果的相关评价、监督和反馈体系尚不完善,医联体内部与外部考核机制之间缺乏有效衔接,使得医联体牵头单位和业务管理部门难以有效评估和管理相关工作。因此,为了使医联体工作达成改革预期目标,建立与医联体相适应的绩效考核体系至关重要。绩效考核应利于持续发展     

基于知识图谱的医疗联合体研究热点和新兴领域探讨

目的 通过文献分析探讨近十年医疗联合（以下简称医联体）的研究热点、新兴领域及其动态变化趋势，为医联体下一步发展和实践提供参考意见。方法 共纳入来源于2009—2019年中国知网的医联体相关文献1 218篇，使用CiteSpace软件绘制医联体研究作者、机构合作关系图谱，通过关键词分析获得研究热点、研究前沿及十年动态变化趋势。结果 医联体作者多以团队合作方式进行研究，但机构间合作不紧密。医联体、紧密型医联体、信息化仍然是目前研究热点。研究前沿不断变化，互联网+医疗、绩效考核、管理机制、专科医联体、康复等成为2019年新兴领域。结论 信息化建设、财务管理、绩效考核、康复、紧密型专科医联体建设等逐渐成为医联体研究中的前沿领域，但仍然需要更多的实证性研究。     

医联体绩效考核要分“三步走”

正近年来,各地分级诊疗制度建设试点取得良好效果。在总结实践经验的基础上,国家卫生健康委员会于近期发布了《关于进一步做好分级诊疗制度建设有关重点工作的通知》和《关于印发医疗联合体综合绩效考核工作方案(试行)的通知》。下一步,医联体建设要在资源规划基础上进行,不能搞"自由恋爱";同时要通过绩效考核指挥棒层层传导,督促医院进一步加强精细化管理,走内涵建设道路。医联体建设不能再"自由恋爱"     

医联体绩效考核:下沉和提升

医联体建设是当前深化医药卫生体制改革的重中之重,是实现分级诊疗就医新秩序的现实路径。要真正建立起利益、责任、服务、管理共同体,就需要建立起一套科学规范,与医联体相适应的绩效考核指标体系,进而在资源规划的基础上,结束"自由恋爱",实现合理配置;终结"跑马圈地",真正实现优质医疗资源下沉和基层服务能力明显提升。然后,怎样的医联体绩效考核是科学、现实、可行,让各方都能加油给力的呢?     

三级公立医院绩效考核中人才培养考核指标的再思考

将医学人才培养工作纳入三级公立医院绩效考核,对我国医疗卫生机构和卫生事业健康可持续发展有着十分重要的意义。笔者对三级公立医院绩效考核中的人才培养指标考核设置、数据统计口径等的科学性和公平性进行梳理分析,提出对医学人才培养指标进行分类考核、统筹医教协同考核、进一步优化医学人才培养成效考核口径等的思考和建议,为进一步完善人才培养考核指标的导向性、科学性、公平性与可操作性提供借鉴。     

长春新碱过量引起严重毒副反应1例的护理体会

报道1例霍奇金淋巴瘤患者因误用长春新碱（VCR）10mg一次性静脉推注后治疗护理情况。其出现间断性神志恍惚、眼睑闭合不全、言语不清、口腔黏膜糜烂、全身疼痛、麻痹性肠梗阻、尿潴留、手足麻木等症状,经积极解救,禁食,持续胃肠减压、胃管内注入麻油、开塞露、生理盐水灌肠,合理应用肠外营养,注重疼痛、心理护理,做好口腔、肛周护理,预防感染加重,患者病情得到控制好转出院。     

Correlates of stages of change of smoking among inhabitants of deprived neighbourhoods

BACKGROUND: This study examines the prevalence and correlates of stages of change of smoking, in terms of psychosocial, structural and sociodemographic factors, among inhabitants of deprived neighbourhoods. METHODS: Cross-sectional data were obtained from a survey on health related behaviour. Subjects were 2009 current and former smokers, aged 20-46, living in deprived neighbourhoods in Rotterdam, the second largest city in the Netherlands. Three groups of smokers were formed according to the stages of change-definitions of the Transtheoretical Model: smokers not planning to quit (precontemplators), smokers planning to quit (contemplators/preparators) and former smokers (actors/maintainers). Smokers planning to quit and smokers not planning to quit were compared regarding psychosocial factors (attitude, social norm, self-efficacy), structural factors (neighbourhood problems, material deprivation, financial problems, employment status) and sociodemographic factors (age, gender, marital status, cultural background, educational level). Former smokers were compared with smokers planning to quit regarding structural and sociodemographic factors. Logistic regression was used to assess correlates of stages of change. RESULTS: Smokers planning to quit (prevalence = 19%) reported a more positive attitude, stronger social norms and higher self-efficacy expectations in quitting smoking than smokers not planning to quit (prevalence = 57%). Smokers planning to quit less often were Dutch-born, more often had attended higher vocational schooling or university and more often reported experiencing two or more neighbourhood problems compared to smokers not planning to quit. Former smokers (prevalence = 24%) were older, more often Dutch-born, married, employed and higher educated, compared to smokers planning to quit. Furthermore, former smokers less often reported material deprivation and financial problems than smokers planning to quit. CONCLUSION: Among people living in deprived neighbourhoods, different factors correlate with different stages of change of smoking. Implications for health promotion are discussed.     

Choice of measures of vaccination and estimates of risk of pediatric pertussis

BackgroundVaccination uptake at the individual level can be assessed in a variety of ways, including traditional measures of being up-to-date (UTD), measures of UTD that consider dose timing, like age-appropriate vaccination, and risk reduction from individual doses. This analysis compared methods of operationalizing vaccination uptake and corresponding risk of pertussis infection.MethodsCity-wide case-control study of children in Philadelphia aged 3 months through 6 years, between 2001 and 2013. Multiple logistic regression was used to isolate the independent effects of each measure of vaccination uptake and the corresponding relative odds of pertussis.ResultsBeing UTD on vaccinations was associated with a 52% reduction in risk of pertussis (OR 0.48, 95% CI: 0.34, 0.69). Evaluation of delayed receipt of vaccine versus on-time UTD yielded similar results. There was a decrease in risk of pertussis for each additional dose received with the greatest reduction in pertussis infection observed from the first (OR 0.48, 95% CI: 0.28, 0.83) and second dose (OR 0.17, 95% CI: 0.08, 0.34). Additional doses conferred minimal additional protection in this age group.ConclusionExamining vaccination status by individual doses may offer improved predictive capacity for identifying children at risk for pertussis infection compared to the traditional UTD measure.     

上海市某医院骨科平均住院日影响因素分析

对上海市某医院2003年-2007年骨科出院病人的住院日描述性分析．2003年-2007年骨科的床位利用指数与平均住院日相关性分析．2003年-2007年骨科床位与医护比例分析．2007年骨科前10大病种平均住院目影响因素分别进行单因素相关性分析和多因素逐步回归分析（STATA软件）。通过对骨科10大病种住院日影响因素分析,术前等待天数、手术类型、是否输血分别对10个、9个和8个病种的住院目有影响。输血因素和手术类型是医院不可控、由病人的病情决定的,术前等待天数是管理因素,是最值得医院重视的影响因素。     

两种不同肌瘤剔除术治疗子宫肌瘤的临床疗效比较

目的:比较腹腔镜子宫肌瘤剔除术与腹式子宫肌瘤剔除术的临床疗效。方法:回顾分析63例腹腔镜子宫肌瘤剔除术与61例腹式子宫肌瘤剔除术的临床资料,比较2种手术方式的手术时间、术中出血量、肛门排气时间、使用抗生素时间、术后感染率、体温恢复正常时间、住院时间等情况。结果:两组患者接受子宫肌瘤剔除术顺利完成,腹腔镜组手术时间长于开腹组(P0.05),腹腔镜组术中出血量及剔除肌瘤个数均少于开腹组(P0.05),术后腹腔镜组体温恢复正常时间、肛门排气时间、抗生素使用及住院时间均短于开腹组,两组患者最多随访6个月,腹腔镜组平均康复时间较开腹组短(P0.05),两组随访B超均未发现明显肌瘤结节。结论:腹腔镜子宫肌瘤剔除术损伤小,恢复快,住院时间短,是值得推广的微创手术。     

尘肺病患者145例死因调查

目的分析汉中市尘肺病的发生、发展和死亡原因，以提高尘肺病患者的生存质量。方法对145例尘肺病患者的死因进行回顾性分析，计算其平均发病年龄、死亡年龄及患尘肺病后的存活年限。结果矽肺的平均发病年龄和死亡年龄均早于煤工尘肺和石棉肺，尘肺病的主要死因为患肺部疾患，患尘肺病后的平均存活年限为12a。结论加强职业健康体检工作，对尘肺病人做到早发现早治疗和预防并发症的发生。     

性发育异常发病机制的研究进展

正常的性腺分化可分为3个过程：原始性腺形成、性别决定和卵巢/睾丸发育。在任一环节中,基因表达或调控发生异常均有可能导致性发育异常疾病的发生。性发育异常是指染色体、性腺和解剖性别不典型。随着分子生物学技术的发展,不断地发现新的基因或信号通路参与性腺分化和发育,如SRY、SF1、WT1、Sox9等基因与睾丸发育密切相关,Wnt/Rspo1/B连环蛋白通路、Dax1、Foxl2等基因在卵巢分化中发挥着重要作用,一些非编码RNA和转化生长因子也有重要的调节功能,且睾丸和卵巢发育均为主动过程,即使在出生后因某些基因的改变两者间也可出现横向分化。这些为揭示性分化异常的发病机制提供了可能。     

One-year stability of the Measure of Processes of Care

BACKGROUND: The Measure of Processes of Care (MPOC) is a 56-item self-administered measure designed to examine what parents of a child with a chronic health problem think of the services they and their child receive, and to measure the extent to which these services are family-centred. Reliability and validity of the MPOC were established in prior studies. The aim of the present study was to assess the 1-year stability of the MPOC to justify its use as an evaluative tool. METHODS: Nine paediatric rehabilitation centres in the Netherlands participated in this short longitudinal survey study. Subjects were 205 parents (response rate 74.8%) of children aged 1-18 years who received care in one of the participating paediatric rehabilitation centres. All subjects filled out two MPOCs with a 1-year interval. RESULTS: All correlations between the scale scores of the MPOC at the first and second administration were relatively high and significant (range: 0.443-0.609, all P < 0.001), demonstrating high inter-individual stability. However, all mean scale scores, except for Providing General Information, significantly reduced after 1 year. CONCLUSIONS: The MPOC has a moderate 1-year stability. However, because of its tendency to score lower when repeated after 1 year, its use as an evaluative follow-up instrument to assess the effectiveness of a programme intervention is restricted.     

儿童皮质发育畸形的MRI诊断

目的探讨儿童皮质发育畸形(MCD)的MRI表现特点,为MCD的早期诊断提供依据。 方法选择2010年1月至2012年12月在四川省医学科学院·四川省人民医院放射科经MRI检查确诊为MCD的44例患儿为研究对象。回顾性分析及总结其MRI影像学特征。本研究遵循的程序符合四川省医学科学院·四川省人民医院人体试验委员会制定的伦理学标准,得到该委员会批准,征得受试对象及其监护人知情同意,并与监护人签署临床研究知情同意书。 结果本组44例经MRI确诊为MCD患儿中,巨脑回-无脑回为17例,多小脑回为14例,灰质异位为9例,脑裂畸形为4例。MCD的MRI特点中,巨脑回表现为脑回增宽、皮质增厚及白质变薄;无脑回表现为正常脑沟、脑回消失,皮质增厚及白质变薄;多小脑回表现为脑回增多、细小;灰质异位表现为皮质下及侧脑室周围深部白质区结节状、团块状或带状病灶,信号与灰质信号相同;脑裂畸形表现为从侧脑室到脑表面贯穿大脑半球的裂隙,表面覆盖灰质。 结论MRI是诊断儿童MCD的可靠影像学方法。     

西林瓶装注射用水的装量检查分析

为了检查西林瓶装注射用水的实际分装量是否符合2005年版《药典》三部要求,按照2005年版《药典》三部中“生物制品分装和冻干规程”,分装规格为0．8ml的西林瓶装注射用水10000瓶,随机在分装过程的前、中、后阶段共抽取100瓶,轧盖、目检。分别用1ml标定注射器及1ml普通无菌注射器抽取每瓶注射用水的实际体积,以t检验法对实际抽取量与标示量的差值进行统计学分析,结果显示其与2005年版《药典》三部要求分装附加量为0．1ml相比有显著性差异（P〈0．001）。